The Quality Payment Program improves Medicare by helping providers focus on care quality and in making patients healthier. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate formula, which threatened clinicians participating in Medicare with potential payment differences for 13 years. If a provider participates in Medicare Part B, s/he is part of the team that serves more than 55 million of the country’s most vulnerable Americans, and the Quality Payment Program (QPR) will provide new tools and resources to help patients get the best possible care. Doctors may choose how to participate based on practice size, specialty, location, or patient population. The Quality Payment Program has two tracks: Advanced Alternative Payment Models (APMs) or The Merit-based Incentive Payment System (MIPS) Participating in an Advanced APM, through Medicare Part B incentive payments are earned with an innovative payment model. Participating in MIPS, a performance-based payment adjustment is earned. Who’s included? Providers in an Advanced APM or if Medicare is billed more than $30,000 a year and care is provided for more than 100 Medicare patients a year. If fewer patients or lower billing amounts, providers are not included in the program. All physicians are required to comply with MACRA rules in 2017 to stop Medicare payment reductions. Based on the data submitted, future reimbursement will be increased or decreased depending on performance using the quality and cost metrics. The new guidelines are based on a complicated scoring system that requires just about every single practice to modify what and how they record their patient encounters. Basically, the metrics reported in 2017 will make a...

Historically, in the 2000s, 2/3 of medical practices were physician-owned and hospitals owned the rest. More recently, physicians are rapidly abandoning private practice so that at this time about ½ are owned by doctors. Why? Well, start with the Affordable Care Act with its thousands of pages of regulations, a bureaucratic nightmare. Doctors spend more and more time (as much as 15 hours a week) on paperwork. EMRs (Electronic Medical Records) added a whole new level of complications and to this date have not worked. Add the fact that private practitioners are paid less by Medicare than the hospitals providing the same service, as much as 40% more!! Centralization to hospitals limits access to care so sick people go to the emergency room because appointments are too difficult to make and are often weeks away. Healthcare costs increase markedly using emergency services. In private practice, doctors depend on the number of patients they see for their income stream. Working for a hospital, they are paid the same no matter how few or many patients they see. De-incentivized for sure. One of the objectives from the health reform project in 2010 (Obama care), stated that the plan would accelerate physician employment by hospitals and create larger physician groups. It worked!! Affordable? What kind of lobby created that? ...

We hear much about the emphasis on improving quality care and even more about how to report and assess it. Performance is being much more closely scrutinized. The idea was to employ the huge benefits expected from electronic health records (EHRs), but that created more problems thus far than it solved. Thus, the assessment still depends on direct reporting and claims data. At the same time, the measures and rules initiated have proliferated to the extent there are over 1000 of them. The result has been abysmal, resulting in mostly chaos. Of course, doctors and their staffs spend inordinate amounts of time trying to figure out how to comply with all of the measures, with projections as high as 15 hours a week per physician. Project the cost over a year and it is substantial. It’s no wonder that the results of all the new applications, the confusion, and the cost have bothered providers to the extent that burnout is a common complaint. Not to mention the alternative payment for Accountable Care (ACO) issues and MACRA (Merit-based Incentive Payment system), (AKA as MIPS). Even though the physician groups that helped design the system disagree with many of the details – like how much risk does the plan pose for that incentivized payment process, and how will performance be graded, etc. Projections show that the larger group practices will likely benefit but the smaller and solo practices will not, thus the expectation is that small practices will pretty much disappear. Stay tuned....

CMS-MEDICARE — MACRA, PQRS, VBPM, MU, MIPSI, etc. My, oh my, you better learn your acronyms if you want to keep up. Hard to focus on what a provider and staff now must do or plan to do within the next few months. Here’s a short list: MACRA (Medicare Access and chip Reauthorization Act of 2015) will definitely impact payments and create more and more overhead. The law will impact Medicare payments by: First, it repeals the SGR (sustainable growth rate) that had calculated payment cuts, then created a way to reward physicians for quality care by establishing payment tracks, merit-based MIPS and alternative payment models (APMs). To make it work, the PQRS (Physician Quality Reporting System),and the VBPM, Value-based Payment Modifier, and MU, Meaningful Use, and the CPIA, Clinical Practice Improvement Activities are to be integrated. Got all that? You really don’t have a couple of years to figure it out since 2017 will determine the baselines for the new payments which are targeted for 2019. What’s the buzz then from the medical professionals? It is projected that 4 out of 10 physicians in solo or small groups will no longer provide services to Medicare patients. Many practices believe they will be penalized as much as 4% under the MACRA act; few (less than 9%) expect any “bonuses.” Approximately one third of solo or small practices will merge to larger ones to meet the problems and expense. CMS (Medicare/Medicaid) actually predicted that those with less than 25 physicians would be penalized based on low performance with failure to provide data as the biggest culprit. Solo practices they predicted...

Warnings continue to providers to avoid copying and pasting medical record information. It is a common practice, (with 89% of physicians surveyed reported doing it) but may create some real problems later in both the payment for services, and in a risk-related legal process. In the pre-EMR years, a study showed about 9 percent of notes in a chart had copied information and 13% of that copied material was either incorrect or misleading which created greater risk in quality care issues and certainly in legal processes. Expand that to 89% and it is clear that the warning should not be ignored. Errors are perpetuated, newer information is missed. Many physicians use a template for entering patient information, copying it into the record and then changing the entries for each patient. But if one of those entries is not updated, it can lead to a missed diagnosis. The time-saving method also raises questions about fraud. Medicare has published they would not pay providers if notes are repeated over a treatment course or are lumped in with other patient information that dealt with similar problems. Legal sharks have been paying close attention too, carefully going through charts looking for copied material. Since the medical record is a legal document, it will clearly show evidence of copied and pasted material which will not help a provider’s defense in the event of a lawsuit. New motto: Copy, paste then REVIEW and EDIT then...

Quality Care Issues and Costs No one can argue that improving quality care is a worthy goal. Interpretation of how it is best done gets bogged down especially when it comes to figuring out what’s required, obtaining and interpreting the information, translating it into inadequate software templates developed by non-medical techs, then reporting it in a way that is manageable for payers. As is commonly reported because so many vendors jumped onto the EMR (electronic medical record) bandwagon to develop proprietary software products, the missing ingredient was standardization. All of those myriad systems now in use by providers cannot talk to each other at all, so much of the effort is wasted, in fact, it has markedly slowed any realistic benefit. A major part of the effort was to create value-based care, that is, what was the patient seen for, what was done and what was the outcome. The idea pushed by Medicare with the Reauthorization Act in 2015 was designed to improve the payment process for value-based care, so providers get paid more if they can prove the care was better? Providers try hard to meet the increasing requirements but how has that affected their practices? A study was done of 1000 practices representing several specialties; the results showed that the office staff averaged 15.1 hours per week per physician to try to fulfill the new standards. The costs were calculated at a surprising $40,000 per physician per year – a whopping $15.4 billion per year spent on just that part of the new regulatory mandates. That does not include the time spent in understanding the rules, trying...